What does it mean to be conscious?
Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.
A normal awake patient has a GCS of 15. A dead patient has a GCS of 3.
Here are further guidelines.
Here are further guidelines.
What is a level of consciousness in children?
www.qureshiuniversity.com/consciousnessinchildren.html
Are all vital signs normal?
Can the person move relevant to age?
Has the person been provided with survival resources?
Does the person or caregiver complaint of anything?
Are these justified complaints?
Ask him or her relevant questions.
Do you have any issues, problems, or complaints as of today?
How should these be included in levels of consciousness?
Sleep
Sedation
Agitation
Not responding to questions while able to hear and see.
What causes it?
Most do not include these in levels of consciousness.
What are the levels of consciousness?
What should be included in the levels of consciousness?
Conscious
Confused
Delirious
Somnolent
Obtunded reflexes
Stuporous
Comatose
Sleepy
Sedated
Agitated
Deaf, mute, blind (hereditary, acquired, temporary, reversible)
Lacking intellectual acuity
If a person is protesting that his or her rights are being violated, what should be documented in the medical record?
Protesting due to his or her rights being violated.
Do not write altered level of consciousness or confusion if a person is protesting.
What is the difference between sleep, general anesthesia, and coma?
General anesthesia is a “drug-induced, reversible condition that includes unconsciousness, amnesia, pain numbing, and inability to move.”
Stability of body functions such as respiration, circulation and temperature regulation.
General anesthesia is pharmacological coma, not sleep.
A coma, on the other hand, is a state of unconsciousness in which people do not interact with the environment.
What are various stages of an altered state of consciousness?
What is an Altered State of Consciousness?
|
Levels of consciousness
|
| Level |
Summary |
Description |
| Conscious |
Normal |
Assessment of LOC involves checking orientation: people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented X3". A normal sleep stage from which a person is easily awakened is also considered a normal level of consciousness."Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness. |
| Confused |
Disoriented; impaired thinking and responses |
People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or "confused". A confused person may be bewildered, disoriented, and have difficulty following instructions. The person may have slow thinking and possible memory time loss. This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection. |
| Delirious |
Disoriented; restlessness, hallucinations, sometimes delusions |
Some scales have "delirious" below this level, in which a person may be restless or agitated and exhibit a marked deficit in attention. |
| Somnolent |
Sleepy |
A somnolent person shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements. |
| Obtunded |
Decreased alertness; slowed psychomotor responses |
In obtundation, a person has a decreased interest in their surroundings, slowed responses, and sleepiness. |
| Stuporous |
Sleep-like state (not unconscious); little/no spontaneous activity |
People with an even lower level of consciousness, stupor, only respond by grimacing or drawing away from painful stimuli. |
| Comatose |
Cannot be aroused; no response to stimuli |
Comatose people do not even make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light. |
How would you describe this patient's level of consciousness?
|
Emotion
| |
Apathetic | |
Motivated | |
Cognitive Log (Cog-Log) | |
Coma Recovery Scale-Revised(CRS-R) | |
Confusion Assessment Protocol (CAP) | |
The Community Balance and Mobility Scale (CB&M) | |
Disability Rating Scale (DRS) | |
The Family Needs Questionnaire (FNQ) | |
High Level Mobility Assessment Tool (HiMAT) | |
Independent Living Scale (ILS) | |
Level of Cognitive Functioning Scale (LCFS) | |
Supervision Rating Scale (SRS)
| |
Altered level of consciousness |
What other historical information is important to help determine the etiology of this patient's problem?
What would be your first step in evaluating this patient?
What part or parts of the nervous system could be implicated in causing her unresponsiveness?
What would be your first step in managing this patient?
|
Both stupor and coma are often further classified as mild, moderate or deep.
What are the causes of an altered state of consciousness?
Table 3 – The Differential Diagnosis of Altered States of Consciousness
A. Disease that cause no focal or lateralizing neurologic signs or alterations of the cellular content of the CSF.
1. Intoxications (alcohol, barbiturates, narcotics)
2. Metabolic disturbances (diabetic acidosis, uremia, hepatic coma, hypoxia, hypoglycemia, Addisonian crisis
3. Severe systemic infections with our without septicemia
4. Circulatory shock from any cause
5. Hypertensive encepalopathy
6. Hypothermia or hyperthermia
7. Status epilepticus
B. Diseases that cause meningeal irritation with either blood or an excess of white blood cells in the CSF, usually without focal or lateralizing signs.
1. Subarachnoid hemorrhage from ruptured aneurysm, occasionally trauma
2. Acute bacterial meningitis
3. Encephalitis
C. Diseases that cause focal or lateralizing signs with our without changes in the CSF. (These may be subdivided into supratentorial and infratentorial lesions). CT and/or MRI are usually positive.
1. Brain hemorrhage
2. Cerebral thrombosis or embolism with secondary brain edema and/or softening
3. Brain abscess
4. Epidural and subdural hematoma with brain contusion and/or compression.
5. Brain tumor
6. Cerebral thrombosis
Metabolic encephalopathies are diffuse disturbances of neuronal function that occur when the substrates required for neuronal metabolism are in short supply, when the internal environment of the cell is disturbed by external agents such as drugs or environmental poisons, or as a complication of the failure of another organ system such as the kidneys, liver or the endocrine, cardiovascular or respiratory systems.
When the metabolic impairment is mild, the onset of symptoms can be insidious and nonspecific. Subtle changes in mentation such as mild drowsiness, dullness of affect, and decreased motor coordination precede the more ominous alteration in the level of consciousness such as confusion, delirium, stupor and eventually coma.
Treatment
Acute Care / Hospitalization
It is apparent that in almost all instances, hospitalization will be required in all serious alterations in the level of consciousness. Until that can be safely accomplished, however, the role of the primary care physician, when confronted by a patient with an altered level of consciousness as a first priority is the institution of emergency treatment necessary to preserve and maintain vital signs and to stabilize the patient to prevent further damage to the nervous system and death. This includes the ABCs of basic life support – airway, breathing and circulation.
An oropharyngeal airway is adequate to keep the pharynx open in patients who are breathing normally. Endotracheal intubation is indicated if there is apnea, upper airway obstruction or emesis, or if the patient is liable to aspirate. Mechanical ventilation will be required if there is hypoventilation. Intravenous access should be established as soon as possible and blood drawn for blood counts, blood chemistry determinations, toxic screen and blood gasses. Definitive Therapy
Dextrose (50% if hypoglycemia is suspected) with added thiamine and naloxone should be administered if hypoglycemia and/or substance abuse are even remote possibilities. Thiamine is helpful in preventing Wernicke’s encephalopathy in malnourished alcoholic individuals. Ultimately, nasogastric intubation and bladder catheterization will probably be necessary. Overdistension of the bladder should be prevented.
Only after initiation of urgent, potentially life-saving measures should a limited physical examination be done primarily to serve as a guide for the care of the patient in his/her transportation to the hospital. Evidence of head trauma should be sought and trauma to the neck and spine should be carefully considered at the time of first contact with the patient. The skull should be palpated for hematomas and the mastoid and periorbital tissues examined for ecchymoses. If neck trauma can be safely excluded, the patient should be placed in a semiprone position so that secretions and vomitus do not enter the endotracheal tree.
The patient should be monitored closely during transportation to the hospital and most ambulances and emergency medical care vehicles are equipped to initiate emergency diagnostic and therapeutic measures. Therapeutic measures that can be instituted enroute to the hospital include treatment of shock and the administration of 100% oxygen by mask. Hypothermia can be helped with blankets and warming devices and hyperthermia by the use of alcohol sponging and the application of cooling solutions. If the patient is conscious, control of anxiety, restlessness and panic may be a problem since all but mild sedation should be avoided.
The hospital should be alerted to the arrival of the patient so that appropriate neurological/neurosurgical consultation will be available for decisions concerning further diagnostic and therapeutic procedures.
Complications
The physician should be alert for the development of complications that may arise during a period of altered consciousness. Confused patients are prone to fall either in walking or getting out of bed. Many of the patients, especially postmenopausal women, will have accompanying osteoporosis and are at increased risk for serious vertebral and hip fractures. Households, hospital and convalescent, nursing and retirement facilities should provide and participate in providing instructions against falling as well as providing safety devices (handrails, etc.) for the prevention of falls. The consequences of hip fractures in this group of patients include long periods of disability and even death.
Precautions should be taken to prevent the bedridden patient with prolonged coma from the development of decubitus ulcers as well as nococomial infections such as pneumonia and bladder infections secondary to an indwelling catheter.
Many of the survivors of an altered state of consciousness will achieve complete or significant recovery of function even in the case of severe head trauma. However, as many as 30 to 40% will remain in prolonged states of severely reduced consciousness subsequent to achieving medical stability.23 The nature of the residual damage depends on the nature and location of the underlying causative agent and the severity of the process.
Relatively few patients will remain in coma, that is, with eyes closed and no evidence of wakefulness for more than four weeks. Patients who show no signs of consciousness after their eyes open usually fit the criteria for the vegetative state (VS). Persistent vegetative state (PVS) is a prognostic term referring to a chronic condition in which basic arousal (i.e., wakefulness) and life-sustaining functions (e.g., respiration, blood pressure) are generally intact despite the absence of behavioral signs of meaningful interaction with the environment. The American Academy of Neurology (AAN) had recently adopted the position that the VS should be termed “persistent” at one month and considered “permanent” after three months following nontraumatic causes of unconsciousness and after twelve months following traumatic injury. However, exceptions to this have been cited.
The locked-in syndrome (LIS) is another residual of the state of altered consciousness. It refers to a specific neurobehavioral diagnosis seen in patients who are alert, cognitively aware of their environment and capable of communication, but cannot move or speak. There are various subclassifications of LIS that relate to the extent of motor and verbal impairment ranging from complete to partial.
Minimally responsive (Min-R) is a descriptive term that refers to patients who are no longer comatose or vegetative, but remain severely disabled. The term should be reserved for use with those patients whose responses are inconsistent but indicative of meaningful interaction with the environment. These patients will respond to a specific command or an environmental prompt (e.g., an attempt to shake an outstretched hand).
Akinetic mutism (AM) is a neurobehavioral condition that is characterized by severely diminished neurologic drive or intention. Although movement and speech are markedly deficient, spontaneously visual tracking is always intact. AM is usually considered a subgroup of the minimally responsive state because meaningful responses are typically inconsistent but can usually be elicited after sensory or pharmacological stimulation.
Most common are residual palsies and paralyses that are usually the residuals of brain damage or a focal lesion such as a brain tumor, hemorrhage, or a cerebrovascular thrombosis or embolism. These are often accompanied by defects in cognition and speech. Seizures may also occur secondary to a focal lesion. Headache, vertigo, light-headedness and hearing loss are also recognized as sequelae to lesions producing ALC, especially head trauma. Most of these bothersome but relatively mild conditions are amenable to palliative or remedial therapies such as physical medicine and rehabilitation, auditory and visual aids, behavioral therapy and biofeedback, and pharmacological agents such as anticonvulsants and antivertigo agents.
Special Circumstances
Vehicular accidents and substance abuse have resulted in an increase in incidence of altered levels of consciousness, especially in adolescents and young adults. The ready availability of motor vehicles in today’s society plus less stringent speed limitations has resulted in an increase in vehicular accidents and head trauma in the younger age groups. In many instances, this has been accompanied by the other burgeoning health problem of substance abuse. An adolescent or young adult seen in an altered level of consciousness in the absence of head trauma or other obvious cause id a definite candidate for drug overdosage and should be handled as such. Tell-tale needle tracks should be sought and nasogastric aspiration should be done to remove any residuals of an ingested agent. After withdrawal of a blood sample for appropriate analyses, the routine administration of naloxone is recommended in these cases. Airway patency should be established and treatment for shock initiated if present.
When to Refer
All ALC patients referred to a hospital should have the benefit of neurological and/or neurosurgical consultation. All such cases will certainly require further diagnostic and therapeutic procedures done by specialized personnel and facilities.
In the patient presenting with delirium or catatonic stupor, psychiatric consultation should be obtained if a functional psychosis is suspected. When mild confusion is seen in an office or outpatient setting and the patient is in no danger of harming himself or others, the primary care physician can resort to appropriate outpatient consultation for diagnostic testing and therapeutic recommendations. The rapid rise in the frequency of occurrence of Alzheimer’s disease poses a problem of this type especially for the elderly.
Prognosis
The Glasgow Coma Scale (see Table 3) has predictive value especially in the case of head injury and traumatic brain injury (TBI). Major points include a 95% death rate in patients whose pupillary reactions or reflex eye movements are absent six hours after the onset of coma and there is a 91% death rate if the pupils are unreactive after 24 hours.
Prognostication of nontraumatic alterations in consciousness is difficult because of the heterogeneity of the contributing disease. Metabolic coma has a generally more favorable prognosis than anoxic or traumatic coma. Statistics of this type from general municipal hospitals tend to be skewed by the preponderance (as high as 60%) of cases due to alcohol. Unfavorable signs in the first hours after admission of a comatose patient include the absence of any two of pupillary reactions, corneal reflex (blinking response to gentle stimulation of the cornea), or the oculovestibular response. The addition of absence of eye opening and muscle tone predict death, progressive disability or the vegetative state.
The prognosis for regaining full mental faculties once the vegetative state is reached is almost nil and physicians are becoming less reluctant to withdraw life-support measures as prediction becomes more accurate.
Waking Conscious
Dreaming Unconscious
Deep Sleep Subconscious
Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.
Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.
Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.
Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.
Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state.
Coma is a state of unarousable unresponsiveness.
| Glasgow Coma Scale |
| |
| ADULT |
|
INFANT |
| Eye opening |
E |
Eye opening |
| Spontaneous |
4 |
Spontaneous |
| To speech |
3 |
To speech |
| To pain |
2 |
To pain |
| No response |
1 |
No response |
| Best motor response |
M |
Best motor response |
| Obeys verbal command |
6 |
Normal movements |
| Localizes pain |
5 |
Localizes pain |
| Flexion - withdraws from pain |
4 |
Withdraws from pain |
| Flexion - abnormal |
3 |
Flexion - abnormal |
| Extension |
2 |
Extension |
| No response |
1 |
No response |
| Best verbal response |
V |
Best verbal response |
| Oriented and converses |
5 |
Coos, babbles |
| Disoriented and converses |
4 |
Cries but consolable |
| Inappropriate words |
3 |
Persistently irritable |
| Incomprehensible sounds |
2 |
Grunts to pain/restless |
| No response |
1 |
No response |
| |
| E + M + V = 3 to 15 |
- 90% less than or equal to 8 are in coma
- Greater than or equal to 9 not in coma
- 8 is the critical score
- Less than or equal to 8 at 6 hours - 50% die
- 9-11 = moderate severity
- Greater than or equal to 12 = minor injury
Coma is defined as not opening eyes, not obeying commands, and not uttering
understandable words. |
|
| Apgar Scale
(evaluate @ 1 and 5 minutes postpartum) |
| |
| |
Sign |
2 |
1 |
0 |
| A |
Activity (muscle tone) |
Active |
Arms and legs flexed |
Absent |
| P |
Pulse |
>100 bpm |
<100 bpm |
Absent |
| G |
Grimace (reflex irritability) |
Sneezes, coughs, pulls away |
Grimaces |
No response |
| A |
Appearance (skin color) |
Normal over entire body |
Normal except extremities |
Cyanotic or pale all over |
| R |
Respirations |
Good, crying |
Slow, irregular |
Absent |
| Pain scale |
| |
|
Patients are asked to rate their pain from 0 (no pain) to 10 (the most intense pain
imaginable), and a quantitative measure is taken. |
States of Consciousness in Newborns
Disorders of consciousness
Medical conditions that inhibit consciousness are considered disorders of consciousness.[109] This category generally includes minimally conscious state and persistent vegetative state, but sometimes also includes the less severe locked-in syndrome and more severe chronic coma.[109][110] Differential diagnosis of these disorders is an active area of biomedical research.[111][112][113] Finally, brain death results in an irreversible disruption of consciousness.[109] While other conditions may cause a moderate deterioration (e.g., dementia and delirium) or transient interruption (e.g., grand mal and petit mal seizures) of consciousness, they are not included in this category.
| Disorder |
Description |
| Locked-in syndrome |
The patient has awareness, sleep-wake cycles, and meaningful behavior (viz., eye-movement), but is isolated due to quadriplegia and pseudobulbar palsy. |
| Minimally conscious state |
The patient has intermittent periods of awareness and wakefulness and displays some meaningful behavior. |
| Persistent vegetative state |
The patient has sleep-wake cycles, but lacks awareness and only displays reflexive and non-purposeful behavior. |
| Chronic coma |
The patient lacks awareness and sleep-wake cycles and only displays reflexive behavior. |
| Brain death |
The patient lacks awareness, sleep-wake cycles, and behavior. |
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